dogs with open metritis and vaginal discharge (Smith, 2006). In addition, anorexia symptoms were not statistically different when comparing dogs with closed metritis (62%) versus open metritis (54%) (Jitpean et al., 2017).
Several other studies have shown that dogs with metritis are mainly open. Jitpean et al. (2014b) studied 11 female dogs with metritis and found that 35% of dogs had closed metritis while the rate of open metritis was up to 65%. In dogs with closed metritis, a general state of moderate to severe depression was more often detected when brought to the clinic than in dogs with open metritis. This may indicate that closed metritis has a worse prognosis, at which time the dog may show symptoms of anorexia. However, in our study, although the rate of anorexia was less frequent, it fell into the group of dogs with open metritis. This can be explained in the case of dogs with open metritis, the phenomenon of fluid accumulation in the uterus makes the animal uncomfortable, when the level of fluid is large enough, it can stimulate the cervix to open and fluid flows out, the stage of pus accumulation in the uterus and fluid discharge can be the stage of blood infection, uterine infection. If the cervix is closed, pus and bacterial products remain in the uterus, often leading to more severe illness than when a little fluid flows through the cervix (Macphail, 2013). The preliminary diagnosis of metritis is determined by medical history data, general health examination and test results combined with X-ray or / and ultrasound showing an enlarged uterus filled with fluid. Therefore, it will cause fever in the animal, when fever is often accompanied by fatigue and anorexia. As for the closed form, it may be due to pus accumulation in the uterus but not large enough to cause blood infection, so the animal is still healthy and eats normally.
Breed-specific differences in incidence have been described (Jitpean et al., 2012; Niskanen & Thrusfield, 1998). Diagnosis is based on history, physical examination, and laboratory analysis, often combined with radiographs or ultrasound of the uterus and ovaries. Clinical signs vary according to the severity of the disease. Metritis can be fatal in 3–4% of cases if left untreated (Egenvall et al., 2001). Metritis in dogs is common.
fatigue, anorexia, when inflammation is severe and fever is high, fatigue and anorexia are more severe.
Thus, anorexia can be considered as a clinical indicator combined with other signs to support the diagnosis of endometritis. However, it is necessary to conduct a careful overview of all indicators, as well as consider the use of ultrasound to diagnose the disease most accurately in order to have timely and effective intervention plans.
4.1.7. Frequency of symptoms of excessive water drinking in dogs with endometritis
When dogs have endometritis, especially purulent endometritis, they often have high fever leading to dehydration and loss of electrolytes, causing dogs to drink a lot of water. In addition, due to the accumulation of secretions inside the uterus, bacteria secrete toxins and are absorbed into the circulation, the body increases the elimination of inflammatory products through the kidneys, so dogs urinate a lot, so female dogs with endometritis often drink a lot of water. To understand the symptoms of drinking water, the study collected data and the results are clearly shown in Table 4.7.
In 136 cases of dogs diagnosed with metritis, polydipsia was present in only 13.97% and the disease was mainly open (57.35%).
In 19 dogs with pyometra that showed symptoms of polydipsia, 4 cases (21.05%) had closed pyometra and 15 cases (78.95%) had open pyometra. Dogs without polydipsia were recorded in 117 cases, including 54 cases with closed pyometra (46.15%) and 63 cases with open pyometra (53.85%). When comparing each type of pyometra, 93.1% of cases did not show polydipsia and only 6.9% of the 58 cases with closed pyometra showed this symptom; of the 78 cases with open pyometra, 80.77% of dogs did not show polydipsia and 19.23% of dogs showed polydipsia.
Table 4.7. Frequency of polydipsia in dogs with metritis
Symptom
Rate (%) | Closed endometritis | Open endometritis | Total between forms of inflammation | |
Don't drink too much water | Frequency | 54 | 63 | 117 |
Rate (%) between types of endometritis | 46.15a | 53.85a | 86.03 I | |
Rate (%) in the form of endometritis | 93.1 I | 80.77 I | ||
Percentage (%) of total | 39.71 A | 46.32 A | ||
Drink plenty of water | Frequency | 4 | 15 | 19 |
Rate (%) between types of endometritis | 21.05a | 78.95 b | 13.97 II | |
Rate (%) in the form of endometritis | 6.9 II | 19.23 II | ||
Percentage (%) of total | 2.94B | 11.03 C | ||
Total in inflammatory form | Frequency | 58 | 78 | 136 |
Rate (%) | 42.65a | 57.35b | 100 |
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Note: In the same row of the proportions of the types of endometritis according to the symptoms of not drinking much water or drinking much water, if the values with the small lowercase letters on the upper right are different, then the difference is statistically significant (P<0.05). In the same column of the proportions of the same type of endometritis between the symptoms of not drinking much water compared to drinking much water, if the values with the small Roman numerals on the upper right are different, then the difference is statistically significant (P<0.05). In the same table of the proportions of each type of endometritis according to each symptom compared to the whole, if the values with the uppercase letters on the upper right are different, then the difference is statistically significant (P<0.05).
The symptom of drinking a lot of water in the open form (78.95%) is higher than in the closed form (21.05%) because the open form is mainly found in cases of severe inflammation, a lot of pus accumulates in the uterus, so it stimulates the cervix to open or when the estrus stage, the cervix opens, the fluid flows out because the secretion accumulates a lot in the uterus, the bacteria
Bacteria secrete toxins and are absorbed into the circulation, the body increases the elimination of inflammatory products through the kidneys, so the dog urinates a lot. The symptoms of drinking a lot of water and increasing kidney function causing polyuria may be multifactorial in origin and may be related to damage to renal tubular cells, impaired ability of the loop of Henle to reabsorb sodium and chloride, and renal tubules not responding to antidiuretic hormone (ADH). Without the presence of ADH, the renal tubules almost lose their permeability to water, leading to a sudden decrease in the ability of the renal tubules to reabsorb water, causing a sudden increase in urine volume, leading to loss of urine concentration.
Other studies have also shown that the degree of electrolyte imbalance may be related to the severity and duration of dehydration. Increased BUN and creatinine levels are common complications of metritis, and they may also be due to dehydration associated with anorexia and vomiting (Hagman, 2014). In dogs with metritis, mean albumin levels were below the reference range, but total protein levels were within the reference range. This means that albumin was either lost through the kidneys or produced at levels below those of liver disease, but levels of acute-phase proteins such as C-reactive protein and gamma globulin, which are produced in response to chronic antigenic stimulation, were increased as a result of acute and chronic inflammation.
In addition, although tubal interstitial inflammation was observed, no age-related glomerular lesions were demonstrated in dogs with metritis. In general, polyuria is reversible after salpingectomy and is most likely due to endotoxin effects. The higher incidence of polydipsia in open than closed metritis may also be influenced by the higher incidence of open metritis in dogs with metritis. Lee et al. (2016) reported that 61.8% of dogs had open metritis while only 38.2% had closed metritis.
According to the study by Lika & cs. (2011) when evaluating clinical symptoms on two groups of dogs with closed metritis and open metritis, the rate of thirst symptoms in dogs with open metritis was 86.6% (13/15 dogs) and in closed metritis was 80% (16/20 dogs). Similar to the study by Jitpean & cs (2014b) when conducted on 356 dogs,
diagnosed with metritis from 2006-2007 at the University Hospital of Veterinary Medicine, Swedish University of Agricultural Sciences showed that polydipsia (or drinking a lot of water) was one of the common clinical symptoms in dogs with metritis, the rate of dogs with polydipsia was 61.6% (180/292). Signs of dehydration also appeared in 26.4% (94/356), pale mucous membranes in 14.6% (52/356). In addition, when evaluating the relationship between clinical signs, physical examination results and laboratory test results with the presence of peritonitis, the risk of prolonged hospitalization after surgery in female dogs with metritis showed that there was no statistically significant difference between the rate of dogs with or without polydipsia in cases of prolonged hospitalization or peritonitis. Similar to the study of Jitpean & cs. (2017) when performed on 72 dogs with open metritis and 39 dogs with closed metritis, showed that the rate of dogs with thirst symptoms in the open metritis group was 54% (39/72) and in the closed metritis group was 62% (24/39), the comparison results were not statistically significant. In addition, when checking the body water retention status in the groups of dogs with metritis, it showed that there was no difference in the rate of no or mild dehydration and moderate or severe dehydration between the group of dogs with open metritis (44%; 56%) and the group with closed metritis (37%; 63%).
Polydipsia and polyuria are common features of metritis (Fransson, 2003). Clinical signs are associated with uterine inflammation and infection and often include polydipsia, polyuria, anorexia, dehydration, and fever. These abnormalities can cause electrolyte and acid-base imbalances and rapidly lead to sepsis or septic shock (Ponce et al., 2009). In addition, when the authors studied metabolic and renal abnormalities in 16 dogs with metritis, 31% (8/16) had acidosis and 19% (3/16) had alkalosis, and 25% (4/16) had elevated lactate. Although half of cases have blood pH within the reference range, arterial blood gas testing is an important part of the care of dogs with metritis because unpredictable acid-base abnormalities can occur (Ponce et al., 2009). Volpato et al. (2012) showed that plasma lactate concentrations were higher in dogs with metritis than in healthy dogs and that there was no effect of coagulation.
dilated cervix to plasma lactate concentration. Plasma lactate concentrations were similar between dogs with closed and open metritis (3.54 ± 0.52 mm to 3.64 ± 1.03 mm). Lactate is considered a useful prognostic indicator in severely ill dogs treated for metritis.
Metritis can be a complication of cystic endometrial hyperplasia, which develops during the luteal phase of the estrous cycle or due to progesterone used to prevent estrus. Deposition of immune complexes in the glomerular capillary wall can cause glomerulonephritis. Loss of renal medullary hypertonicity has been described as the cause of polyuria in dogs with metritis. Polyuria can also result from decreased sensitivity of the renal V2 receptors, which are responsible for the action of ADH on the kidney, and ADH deficiency leads to reduced water reabsorption leading to polyuria. Thus, polydipsia can be considered as a clinical indicator in combination with other signs to support the diagnosis of metritis. However, a careful review of all clinical indicators is needed, as well as consideration of the use of ultrasound to make the most accurate diagnosis in order to have a timely and effective intervention plan.
4.1.8. Frequency of fever symptoms in dogs with metritis
Under normal conditions, body temperature is always maintained in a very narrow temperature range to facilitate cell metabolism and normal functioning of organs in the body. Fever is a protective reaction of the body to fight pathogens, especially inflammation and infection. Dogs with metritis often have pus accumulation inside, the final stage can cause blood infection that produces toxins that cause fever. The frequency of fever in dogs with metritis occurs in the forms shown in Table 4.8.
The results are shown in Table 4.8 on the presence or absence of fever symptoms in 136 dogs and the incidence of different types of metritis, showing that dogs with closed metritis were lower than those with open metritis (42.65% vs. 57.35%). In particular, for the closed and open metritis groups, the majority of dogs with metritis did not have fever symptoms, which was higher than the dogs with this symptom in each group (89.66% and 10.34%; 84.62% and 10.34%, respectively).
15.38%). When comparing the groups with and without fever symptoms in terms of the incidence of the two types of metritis, dogs with open metritis were higher than those with closed metritis (66.67% and 33.33%; 55.93% and 44.07%). However, there was no statistically significant difference between these comparison indicators.
Table 4.8. Frequency of fever in dogs with metritis
Symptom
Rate (%) | Closed endometritis | Open endometritis | Total between forms of inflammation | |
No fever | Frequency | 52 | 66 | 118 |
Rate (%) between types of endometritis | 44.07a | 55.93a | 86.76 I | |
Rate (%) in the form of endometritis | 89.66 I | 84.62 I | ||
Percentage (%) of total | 38.24 A | 48.53B | ||
Fever | Frequency | 6 | 12 | 18 |
Rate (%) between types of endometritis | 33.33a | 66.67b | 13.24 II | |
Rate (%) in the form of endometritis | 10.34 II | 15.38 II | ||
Percentage (%) of total | 4.41 C | 8.82 C | ||
Total in inflammatory form | Frequency | 58 | 78 | 136 |
Rate (%) | 42.65a | 57.35b | 100 |
Note: In the same row of the proportions of the types of endometritis according to the symptoms of no fever or fever, if the values with the small lowercase letters on the upper right are different, they are statistically significantly different (P<0.05). In the same column of the proportions of the same type of endometritis between the symptoms of no fever compared to those with fever, if the values with the small Roman numerals on the upper right are different, they are statistically significantly different (P<0.05). In the same table of the proportions of each type of endometritis according to each symptom compared to the whole, if the values with the small uppercase letters on the upper right are different, they are statistically significantly different (P<0.05).
Fever is a condition of increased body temperature due to disturbance of the thermoregulatory center under the influence of harmful factors, usually infection. Bitches with pyometra often suffer from dehydration, sepsis, intoxication and fever. In cases of metritis with blood poisoning, hypothermia may occur. When sick, animals are often infected with toxins from bacteria. Endotoxins are lipopolysaccharides part of the outer cell wall of Gram-negative bacteria, such as E. coli , and endotoxins are formed and circulated during bacterial growth or cell breakdown and interact with inflammation and endothelial cells. When present in the blood, endotoxins cause a variety of biological effects and symptoms such as fever, lethargy and increased heart rate and respiratory rate. Endotoxins complement and activate the coagulation cascade, activate platelets, produce active kinins, cytokines, free oxygen radicals, arachidonic acid-derived prostaglandins, tromboxanes, and platelet-activating factor. Moderate production of these substances is beneficial for stimulating the immune system and killing microorganisms. However, the release of large amounts of endotoxins can lead to fatal endotoxic shock with circulatory and reticuloendothelial system failure. Circulating endotoxins can also directly induce endothelial damage, disseminated intravascular coagulation, and systemic organ failure. Under normal physiological conditions, small amounts of endotoxins derived from enteric bacteria continuously migrate through the intestinal mucosa and enter the circulation. Endotoxins are then filtered by the Kuppfer cells and hepatocytes of the liver, preventing systemic endotoxemia (Fox et al., 1990). Normally, clearance of endotoxin from the circulation occurs within minutes and symptoms only develop when liver capacity is exceeded. Blood endotoxin levels have previously been associated with outcome (survival or death) in cases of metritis (Okano et al., 1998). Bitches that died from the disease had significantly higher endotoxin levels (mean 74.2 pg ml-1) than those that survived (mean 9.5 pg ml-1). This suggests that endotoxin could be used as a marker for disease severity and to determine the chance of survival. Early detection of blood endotoxin would allow therapeutic intervention to prevent further development of sepsis. All these results suggest that endotoxin is involved in endometritis, but it is not always detectable due to variations in blood concentrations and in sampling and analytical procedures.